 |
|
(s) "Forms prescribed by the office" means either of the following:
(1) Cost reporting forms provided by the office.
(2) Substitute forms that have received prior written approval by the office.
(t) "General line personnel" means management personnel above the department head level who perform a policymaking or supervisory function impacting directly on the operation of the facility.
(u) "Generally accepted accounting principles" or "GAAP" means those accounting principles as established by the American Institute of Certified Public Accountants.
(v) "Incomplete MDS resident assessment" means an assessment that is not printed by the nursing facility provider upon request by the office or its contractor.
(w) "Indirect care component" means the portion of the Medicaid rate that shall reimburse providers for allowable indirect patient care services and supplies, including prorated employee benefits based on salaries and wages. Indirect care services and supplies include the following:
(1) Dietary services and supplies.
(2) Raw food.
(3) Patient laundry services and supplies.
(4) Patient housekeeping services and supplies.
(5) Plant operations services and supplies.
(6) Utilities.
(7) Social services.
(8) Activities supplies and services.
(9) Recreational supplies and services.
(10) Repairs and maintenance.
(11) Cable or satellite television throughout the nursing facility, including residents' rooms.
(12) Pets, pet supplies and maintenance, and veterinary expenses.
(13) Educational seminars for indirect care staff.
(14) All costs related to nonambulance travel and transportation of residents.
(x) "Medical and nonmedical supplies and equipment" includes those items generally required to assure adequate medical care and personal hygiene of patients.
(y) "Minimum data set" or "MDS" means a core set of screening and assessment elements, including common definitions and coding categories, that form the foundation of the comprehensive assessment for all residents of long-term care facilities certified to participate in the Medicaid program. The items in the MDS standardize communication about resident problems, strengths, and conditions within facilities, between facilities, and between facilities and outside agencies. Version 2.0 (9/2000) is the most current form to the minimum data set (MDS 2.0). The Indiana system will employ the MDS 2.0 or subsequent revisions as approved by the Centers for Medicare and Medicaid Services (CMS).
(z) "Normalized allowable cost" means total allowable direct patient care costs for each facility divided by that facility's average CMI for all residents.
(aa) "Nursing home report card score" means a numerical score developed and published by the Indiana state department of health (ISDH) that quantifies each facility's key survey results.
(bb) "Office" means the office of Medicaid policy and planning.
(cc) "Ordinary patient-related costs" means costs of allowable services and supplies that are necessary in delivery of patient care by similar providers within the state.
(dd) "Patient/recipient care" means those Medicaid program services delivered to a Medicaid enrolled recipient by a certified Medicaid provider.
(ee) "Reasonable allowable costs" means the price a prudent, cost-conscious buyer would pay a willing seller for goods or services in an arm's-length transaction, not to exceed the limitations set out in this rule.
(ff) "Related party/organization" means that the provider:
(1) is associated or affiliated with; or
(2) has the ability to control or be controlled by;
the organization furnishing the service, facilities, or supplies, whether or not such control is actually exercised.
(gg) "Routine care" means care that does not treat or ameliorate a specific defect or specific physical or mental illness or condition.
(1) Has a locked, secure, segregated unit or provides a special program or special unit for residents with Alzheimer's disease, related disorders, or dementia.
(2) The facility advertises, markets, or promotes the health facility as providing Alzheimer's care services or dementia care services, or both.
(3) The nursing facility has a designated director for the Alzheimer's and dementia special care unit, who satisfies all of the following conditions:
(A) Became the director of the SCU prior to August 21, 2004, or has earned a degree from an educational institution in a health care, mental health, or social service profession, or is a licensed health facility administrator.
(B) Has a minimum of one (1) year work experience with dementia or Alzheimer's, or both, residents within the past five (5) years.
(C) Completed a minimum of twelve (12) hours of dementia specific training within three (3) months of initial employment and has continued to obtain six (6) hours annually of dementia-specific training thereafter to:
(i) meet the needs or preferences, or both, of cognitively impaired residents; and
(ii) gain understanding of the current standards of care for residents with dementia.
(D) Performs the following duties:
(i) Oversees the operations of the unit.
(ii) Ensures personnel assigned to the unit receive required in-service training.
(iii) Ensures the care provided to Alzheimer's and dementia care unit residents is consistent with in-service training, current Alzheimer's and dementia care practices, and regulatory standards.
(1) are not supported according to the MDS supporting documentation guidelines as set forth in
(2) result in the assessment being classified into a different RUG-III category.
SECTION 8.
Authority: |
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| Effective Date | Midpoint Quarter |
| January 1, Year 1 | July 1, Year 1 |
| April 1, Year 1 | October 1, Year 1 |
| July 1, Year 1 | January 1, Year 2 |
| October 1, Year 1 | April 1, Year 2 |
(b) Notwithstanding subsection (a), beginning July 1, 2014, 2017, the inflation adjustment determined as prescribed in subsection (a) shall be reduced by an inflation reduction factor equal to three and three-tenths percent (3.3%). The resulting inflation adjustment shall not be less than zero (0). Any reduction or elimination of the inflation reduction factor shall be made effective no earlier than permitted under IC 12-15-13-6 (a).
(c) In determining prospective allowable costs for a new provider that has undergone a change of provider ownership or control through an arm's-length transaction between unrelated parties, when the first fiscal year end following the change of provider ownership or control is less than six (6) full calendar months, the previous provider's most recently completed annual financial report used to establish a Medicaid rate for the previous provider shall be utilized to calculate the new provider's first annual rate review. The inflation adjustment for the new provider's first annual rate review shall be applied from the midpoint of the previous provider's most recently completed annual financial report period to the midpoint prescribed under subsection (a).
(d) Allowable fixed costs per patient day for direct care, indirect care, and administrative costs shall be computed based on the following minimum occupancy levels:
(1) For nursing facilities with less than fifty-one (51) beds, an occupancy rate equal to the greater of eighty-five percent (85%) or the provider's actual occupancy rate from the most recently completed historical period.
(2) For nursing facilities with greater than fifty (50) beds, an occupancy rate equal to the greater of ninety percent (90%) or the provider's actual occupancy rate from the most recently completed historical period.
(e) Notwithstanding subsection (d), the office or its contractor shall reestablish a provider's Medicaid rate effective on the first day of the quarter following the date that the conditions specified in this subsection are met, by applying all provisions of this rule, except for the applicable minimum occupancy requirement described in subsection (d), if both of the following conditions can be established to the satisfaction of the office:
(1) The provider demonstrates that its current resident census has:
(A) increased to the applicable minimum occupancy level described in subsection (d), or greater since the facility's fiscal year end of the most recently completed and desk reviewed cost report utilizing total nursing facility licensed beds as of the most recently completed and desk reviewed cost report period; and
(B) remained at such level for not fewer than ninety (90) days.
(2) The provider demonstrates that its resident census has:
(A) increased by a minimum of fifteen percent (15%) since the facility's fiscal year end of the most recently completed and desk reviewed cost report; and
(B) remained at such level for not fewer than ninety (90) days.
(f) Allowable fixed costs per patient day for capital-related costs shall be computed based on an occupancy rate equal to the greater of ninety-five percent (95%) or the provider's actual occupancy rate from the most recently completed historical period.
(g) Except as provided for in subsection (h), the CMIs contained in this subsection shall be used for purposes of determining each resident's CMI used to calculate the facility-average CMI for all residents and the facility-average CMI for Medicaid residents.
| RUG-III Group | RUG-III Code | CMI Table |
| Rehabilitation | RAD | 2.02 |
| Rehabilitation | RAC | 1.69 |
| Rehabilitation | RAB | 1.50 |
| Rehabilitation | RAA | 1.24 |
| Extensive Services | SE3 | 2.69 |
| Extensive Services | SE2 | 2.23 |
| Extensive Services | SE1 | 1.85 |
| Special Care | SSC | 1.75 |
| Special Care | SSB | 1.60 |
| Special Care | SSA | 1.51 |
| Clinically Complex | CC2 | 1.33 |
| Clinically Complex | CC1 | 1.27 |
| Clinically Complex | CB2 | 1.14 |
| Clinically Complex | CB1 | 1.07 |
| Clinically Complex | CA2 | 0.95 |
| Clinically Complex | CA1 | 0.87 |
| Impaired Cognition | IB2 | 0.93 |
| Impaired Cognition | IB1 | 0.82 |
| Impaired Cognition | IA2 | 0.68 |
| Impaired Cognition | IA1 | 0.62 |
| Behavior Problems | BB2 | 0.89 |
| Behavior Problems | BB1 | 0.77 |
| Behavior Problems | BA2 | 0.67 |
| Behavior Problems | BA1 | 0.54 |
| Reduced Physical Functions | PE2 | 1.06 |
| Reduced Physical Functions | PE1 | 0.96 |
| Reduced Physical Functions | PD2 | 0.97 |
| Reduced Physical Functions | PD1 | 0.87 |
| Reduced Physical Functions | PC2 | 0.83 |
| Reduced Physical Functions | PC1 | 0.76 |
| Reduced Physical Functions | PB2 | 0.73 |
| Reduced Physical Functions | PB1 | 0.66 |
| Reduced Physical Functions | PA2 | 0.56 |
| Reduced Physical Functions | PA1 | 0.50 |
| Unclassifiable | BC1 | 0.48 |
| Delinquent | BC2 | 0.48 |
(h) In place of the CMIs contained in subsection (g), the CMIs contained in this subsection shall be used for purposes of determining the facility-average CMI for Medicaid residents that meet all the following conditions:
(1) The resident classifies into one (1) of the following RUG-III groups:
(A) PB2.
(B) PB1.
(C) PA2.
(D) PA1.
(2) The resident has a cognitive status indicated by a brief interview of mental status score (BIMS) greater than or equal to ten (10) or, if there is not a BIMS score, then a cognitive performance score (CPS) of:
(A) zero (0) – Intact;
(B) one (1) – Borderline Intact; or
(C) two (2) – Mild Impairment.
(3) Based on an assessment of the resident's continence control as reported on the MDS, the resident is not experiencing occasional, frequent, or complete incontinence. control.
(4) The resident has not been admitted to any Medicaid-certified nursing facility before January 1, 2010.
(5) If the office or its contractor determines that a nursing facility has delinquent MDS resident assessments that are assigned a CMI in accordance with this subsection, then, for purposes of determining the facility's average CMI for Medicaid residents, the assessment or assessments shall be assigned ninety-six percent (96%) of the CMI associated with the RUG-III group determined in this subsection.
| RUG-III Group | RUG-III Code | CMI Table |
| Reduced Physical Functions | PB2 | 0.30 |
| Reduced Physical Functions | PB1 | 0.28 |
| Reduced Physical Functions | PA2 | 0.24 |
| Reduced Physical Functions | PA1 | 0.21 |
(i) The office or its contractor shall provide each nursing facility with the following:
(1) A preliminary CMI report that will:
(A) serve as confirmation of the MDS assessments transmitted by the nursing facility; and
(B) provide an opportunity for the nursing facility to correct and transmit any missing or incorrect MDS assessments.
The preliminary report will be provided by the twenty-fifth day of the first month following the end of a calendar quarter.
(2) Final CMI reports utilizing MDS assessments received by the fifteenth day of the second month following the end of a calendar quarter. These assessments received by the fifteenth day of the second month following the end of a calendar quarter will be utilized to establish the facility-average CMI and facility-average CMI for Medicaid residents utilized in establishing the nursing facility's Medicaid rate.
(j) The office will increase Medicaid reimbursement to nursing facilities that provide inpatient services to more than eight (8) ventilator-dependent residents. Additional reimbursement shall be made to the facilities at a rate of eleven dollars and fifty cents ($11.50) per Medicaid resident day. The additional reimbursement shall:
(1) be effective on the day the nursing facility provides inpatient services to more than eight (8) ventilator-dependent residents; and
(2) remain in effect until the first day of the calendar quarter following the date the nursing facility provides inpatient services to eight (8) or fewer ventilator-dependent residents.
(k) Beginning October 1, 2011, through June 30, 2013, the office will increase Medicaid reimbursement to nursing facilities to encourage improved quality of care to residents based on the nursing home report card score. For purposes of determining the nursing home report card score rate add-on the office or its contractor shall determine each nursing facility's report card score based on the latest published data as of the end of the state fiscal year. The nursing home report card score rate add-on shall be computed as described in the following table:
| Nursing Home Report Card Score | Nursing Home Report Card Score Rate Add-On |
| 0 – 82 | $14.30 |
| 83 – 265 | $14.30 – ((Nursing Home Report Card Score – 82) × $0.0777) |
| 266 and above | $0 |
Facilities that did not have a nursing home report card score published as of the most recently completed state fiscal year may receive a per patient day rate add-on equal to two dollars ($2).
(l) Beginning effective July 1, 2003, Through June 30, 2014, 2017, the office will increase Medicaid reimbursement to nursing facilities that provide specialized care to residents with Alzheimer's disease or dementia, as demonstrated by resident assessment data as of December 31 of each year. Medicaid Alzheimer Alzheimer's and dementia residents shall be determined to be in the SCU based on an exact match of room numbers reported on Schedule Z with the room numbers reported on resident assessments and tracking forms. Resident assessments and tracking forms with room numbers that are not an exact match to the room numbers reported on Schedule Z will be excluded in calculating the number of Medicaid Alzheimer Alzheimer's and dementia resident days in their SCU. The additional Medicaid reimbursement shall equal twelve dollars ($12) per Medicaid Alzheimer Alzheimer's and dementia resident day in their SCU. Only facilities that meet the definition for a SCU for Alzheimer's disease or dementia shall be eligible to receive the additional reimbursement. The additional Medicaid reimbursement shall be effective July 1 of the next state fiscal year.
(m) Beginning July 1, 2013, Through June 30, 2014, 2017, the office will increase Medicaid reimbursement to nursing facilities to encourage improved quality of care to residents based on each facility's total quality score. For purposes of determining the nursing facility quality rate add-on, each facility's total quality score will be determined annually. Each nursing facility's quality rate add-on shall be determined as follows:
| Nursing Facility Total Quality Score | Nursing Facility Quality Rate Add-On |
| 0 – 18 | $0 |
| 19 – 83 | $14.30 – ((84 - Nursing Facility Total Quality Score) × 0.216667) |
| 84 – 100 | $14.30 |
(n) Each nursing facility shall be awarded no more than one hundred (100) quality points as determined by the following eight (8) quality measures:
(Office of the Secretary of Family and Social Services; (1) Nursing home report card score. The office or its contractor shall determine each nursing facility's quality points using the report card score published by the Indiana state department of health. Each nursing facility shall be awarded not more than seventy-five (75) quality points based on its nursing home report card score. Each nursing facility's quality points shall be determined using each nursing facility's most recently published report card score as of June 30, 2013, and each June 30 thereafter. Each nursing facility's quality points under this subdivision shall be determined as follows:
| Nursing Home Report Card Scores | Quality Points Awarded |
| 0 – 82 | 75 |
| 83 – 265 | Proportional quality points awarded as follows: |
| 75 – [(facility report card score – 82) × 0.407609]] | |
| 266 and above | 0 |
Facilities that did not have a nursing home report card score published as of June 30, 2013, or each June 30 thereafter, shall be awarded the statewide average quality points for this measure.
(2) Normalized weighted average nursing hours per resident day. The office or its contractor shall determine each nursing facility's normalized weighted average nursing hours per resident day using data from its annual financial report. Nursing hours per resident day include nurse staff hours for RN, LPN, nursing assistants, and other nursing personnel categories. Nursing hours per resident day for each nurse staff category shall be weighted by the facility-specific CNA average wage rates, and normalized by dividing each facility's weighted average nursing hours per resident day by the facility's case mix index for all residents. Each nursing facility shall be awarded not more than ten (10) quality points based on the normalized weighted average nursing hours per resident day. Quality points shall be determined using each nursing facility's most recently completed annual financial report as of June 30, 2013, and each June 30 thereafter. Each nursing facility's quality points under this subdivision shall be determined as follows:
| Normalized Weighted Average Nursing Hours Per Resident Day | Quality Points Awarded |
| Less than or equal to 3.315 | 0 |
| Greater than 3.315 and less than 4.401 | Proportional quality points awarded as follows: |
| 10 – [(4.401 – facility's normalized weighted average nursing hours per resident day) × 9.208103] | |
| Equal to or greater than 4.401 | 10 |
Facilities that are a new operation and did not have a normalized weighted average nursing hours per resident day from the most recently completed annual financial report as of June 30, 2013, or each June 30 thereafter, shall be awarded the statewide average quality points for this measure.
(3) RN/LPN retention rate. The office or its contractor shall determine each nursing facility's RN/LPN retention rate using data from its Schedule X. Each nursing facility shall be awarded no more than three (3) quality points based on the facility's RN/LPN retention rate. Quality points shall be determined using each nursing facility's most recently completed Schedule X as of March 31, 2013, and each March 31 thereafter. Each nursing facility's quality points under this subdivision shall be determined as follows:
| Nursing Facility's RN/LPN Retention Rates | Quality Points Awarded |
| Less than or equal to 58.3% | 0 |
| Greater than 58.3% and less than 83.3% | Proportional quality points awarded as follows: |
| 3 – [(83.3% - facility's annual RN/LPN retention rate) × 12] | |
| Equal to or greater than 83.3% | 3 |
Facilities that are a new operation and did not have RNs/LPNs for the entire calendar year preceding March 31, 2013, or each March 31 thereafter, shall be awarded the statewide average quality points for this measure. Facilities that did not submit a Schedule X as of March 31 shall receive zero (0) quality points for this measure.
(4) CNA retention rate. The office or its contractor shall determine each nursing facility's CNA retention rate using data from its Schedule X. Each nursing facility shall be awarded no more than three (3) quality points based on the facility's CNA retention rate. Quality points shall be determined using each nursing facility's most recently completed Schedule X as of March 31, 2013, and each March 31 thereafter. Each nursing facility's quality points under this subdivision shall be determined as follows:
| Nursing Facility's CNA Retention Rates | Quality Points Awarded |
| Less than or equal to 49.5% | 0 |
| Greater than 49.5% and less than 76.0% | Proportional quality points awarded as follows: |
| 3 – [(76.0% – facility's annual CNA retention rate) × 11.320755] | |
| Equal to or greater than 76.0% | 3 |
Facilities that are a new operation and did not have CNAs for the entire calendar year preceding March 31, 2013, or each March 31 thereafter, shall be awarded the statewide average quality points for this measure. Facilities that did not submit a Schedule X as of March 31 shall receive zero (0) quality points for this measure.
(5) RN/LPN turnover rate. The office or its contractor shall determine each nursing facility's RN/LPN turnover rate using data from its Schedule X. Each nursing facility shall be awarded not more than one (1) quality point based on the facility's RN/LPN turnover rate. Quality points shall be determined using each nursing facility's most recently completed Schedule X as of March 31, 2013, and each March 31 thereafter. Each nursing facility's quality points under this subdivision shall be determined as follows:
| Nursing Facility's Annual RN/LPN Turnover Rate | Quality Points Awarded |
| Less than or equal to 26.1% | 1 |
| Greater than 26.1% and less than 71.4% | Proportional quality points awarded as follows: |
| 1 – [(26.1% – facility's annual RN/LPN turnover rate) × (-2.207506)] | |
| Equal to or greater than 71.4% | 0 |
Facilities that are a new operation and did not have RNs/LPNs for the entire calendar year preceding March 31, 2013, or each March 31 thereafter, shall be awarded the statewide average quality points for this measure. Facilities that did not submit a Schedule X as of March 31 shall receive zero (0) quality points for this measure.
(6) CNA turnover rate. The office or its contractor shall determine each nursing facility's CNA turnover rate using data from its Schedule X. Each nursing facility shall be awarded no more than two (2) quality points based on the facility's CNA turnover rate. Quality points shall be determined using each nursing facility's most recently completed Schedule X as of March 31, 2013, and each March 31 thereafter. Each nursing facility's quality points under this subdivision shall be determined as follows:
| Nursing Facility Annual CNA Turnover Rates | Quality Points Awarded |
| Less than or equal to 39.4% | 2 |
| Greater than 39.4% and less than 96.2% | Proportional quality points awarded as follows: |
| 2 – [39.4% – facility's annual CNA turnover rate) × (-3.521127)] | |
| Equal to or greater than 96.2% | 0 |
Facilities that are a new operation and did not have a CNA for the entire calendar year preceding March 31, 2013, or each March 31 thereafter, shall be awarded the statewide average quality points for this measure. Facilities that did not submit a Schedule X as of March 31 shall receive zero (0) quality points for this measure.
(7) Administrator turnover. The office or its contractor shall determine each nursing facility's administrator turnover rate using data from its Schedule X. The nursing facility administrator turnover rate shall be based on the number of nursing home administrators employed or designated by the facility during the most recent five (5) year period. A nursing facility administrator hired on a temporary basis due to a documented medical or other temporary leave of absence shall not be counted in cases where the previous administrator is reasonably expected to return to the position and whose employment or designation as facility administrator is not terminated. Any such leave of absence shall be documented to the satisfaction of the office. Each nursing facility shall be awarded not more than three (3) quality points based on the facility's administrator turnover rate. Quality points shall be determined using each nursing facility's most recently completed Schedule X as of March 31, 2013, and each March 31 thereafter. Each nursing facility's quality points under this subdivision shall be determined as follows:
| Number of Administrators Employed Within the | Quality Points Awarded |
| 6 or more | 0 |
| 5 | 1 |
| 4 | 2 |
| 3 or fewer | 3 |
Facilities that did not have a facility administrator employed or designated for the previous five (5) years shall be awarded the statewide average quality points for this measure. Facilities that did not submit a Schedule X as of March 31 shall receive zero (0) quality points for this measure.
(8) Director of nursing (DON) turnover. The office or its contractor shall determine each nursing facility's DON turnover rate using data from its Schedule X. The nursing facility DON turnover rate shall be based on the number of DONs employed or designated by the facility during the most recent five (5) year period. A nursing facility DON hired on a temporary basis due to a documented medical or other temporary leave of absence shall not be counted in cases where the previous DON is reasonably expected to return to the position and whose employment or designation as facility DON is not terminated. Any such leave of absence shall be documented to the satisfaction of the office. Each nursing facility shall be awarded no more than three (3) quality points based on the number of DONs employed or designated by the facility during the most recent five (5) year period. Quality points shall be determined using each nursing facility's most recently completed Schedule X as of March 31, 2013, and each March 31 thereafter. Each nursing facility's quality points under this subdivision shall be determined as follows:
| Number of DONs Employed Within the | Quality Points Awarded |
| 6 or more | 0 |
| 5 | 1 |
| 4 | 2 |
| 3 or fewer | 3 |
Facilities that did not have a facility DON employed or designated for the previous five (5) years shall be awarded the statewide average quality points for this measure. Facilities that did not submit a Schedule X as of March 31 shall receive zero (0) quality points for this measure.
SECTION 10. 405 IAC 1-14.6-9 IS AMENDED TO READ AS FOLLOWS:
405 IAC 1-14.6-9 Rate components; rate limitations; profit add-on
Authority: Affected: IC 12-13-7-3 ; IC 12-15-13-6
Sec. 9. (a) The Medicaid reimbursement system is based on recognition of the provider's allowable costs for the direct care, therapy, indirect care, administrative, and capital components, plus a potential profit add-on payment as defined below. The direct care, therapy, indirect care, administrative, and capital rate components are calculated as follows:
(1) The direct care component is equal to the provider's normalized allowable per patient day direct care costs times the facility-average CMI for Medicaid residents, plus the allowed profit add-on payment as determined by the methodology in subsection (b).
(2) The therapy component is equal to the provider's allowable Medicaid per patient day direct therapy costs.
(3) The indirect care and capital components are equal to the provider's allowable per patient day costs for each component, plus the allowed profit add-on payment as determined by the methodology in subsection (b).
(4) The administrative component shall be equal to one hundred percent (100%) of the average allowable cost of the median patient day.
(b) The profit add-on payment will be calculated as follows:
(1) For nursing facilities designated by the office as children's nursing facilities, the allowed direct care component profit add-on is equal to the profit add-on percentage contained in Table 1, times the difference (if greater than zero (0)) between:
(A) the normalized average allowable cost of the median patient day for direct care costs times the facility average CMI for Medicaid residents times the profit ceiling percentage contained in Table 1; minus
(B) the provider's normalized allowable per patient day costs times the facility average CMI for Medicaid residents.
| Table 1 | ||||
| Children's Nursing Facilities | ||||
| Effective Date | Direct Care Profit Add-on Percentage | Direct Care Profit Ceiling Percentage | ||
| July 1, 2003, through June 30, | July 1, | July 1, 2003, through June 30, | July 1, |
|
| Percentage | 30% | 52% | 110% | 105% |
(2) For nursing facilities that are not designated by the office as children's nursing facilities, the tentative direct care component profit add-on payment is equal to the profit add-on percentage contained in Table 2, times the difference (if greater than zero (0)) between:
(A) the normalized average allowable cost of the median patient day for direct care costs times the facility average CMI for Medicaid residents times the profit ceiling percentage contained in Table 2; minus
(B) the provider's normalized allowable per patient day costs times the facility average CMI for Medicaid residents.
| Table 2 | ||||
| Non-Children's Nursing Facilities | ||||
| Effective Date | Direct Care Profit Add-on Percentage | Direct Care Profit Ceiling Percentage | ||
| July 1, 2003, through June 30, | July 1, | July 1, 2003, through June 30, | July 1, |
|
| Percentage | 30% | 0% | 110% | 105% |
(C) For nursing facilities not designated by the office as children's nursing facilities, the allowed direct care component profit add-on payment is equal to the facility's tentative direct care component profit add-on payment times the applicable percentage contained in Table 3, based on the facility's nursing home report card score as determined by the office or its contractor using the latest published data as of the end of each state fiscal year, or the facility's total quality score. as applicable.
| Table 3 | |
| Total Quality Score | Percentage |
| 84 – 100 | 100% |
| 19 – 83 | 100% + ((Total Quality Score – 84) / 66) |
| 18 and below | 0% |
(D) In no event shall the allowed direct care profit add-on payment exceed ten percent (10%) of the average allowable cost of the median patient day.
(3) The tentative indirect care component profit add-on payment is equal to the profit add-on percentage contained in Table 4, times the difference (if greater than zero (0)) between:
(A) the average allowable cost of the median patient day times the profit ceiling percentage contained in Table 4; minus
(B) a provider's allowable per patient day cost.
| Table 4 | ||||
| Effective Date | Indirect Care Profit Add-on Percentage | Indirect Care Profit Ceiling Percentage | ||
| July 1, 2003, through June 30, | July 1, | July 1, 2003, through June 30, | July 1, |
|
| Percentage | 60% | 52% | 105% | 100% |
(C) The allowed indirect care component profit add-on payment is equal to the facility's tentative indirect care component profit add-on payment times the applicable percentage contained in Table 3, based on the facility's nursing home report card score as determined by the office or its contractor using the latest published data as of the end of each state fiscal year, or the facility's total quality score. as applicable.
(4) The tentative capital component profit add-on payment is equal to sixty percent (60%) times the difference (if greater than zero (0)) between:
(A) the average allowable cost of the median patient day times the profit ceiling percentage contained in Table 5; minus
(B) a provider's allowable per patient day cost.
| Table 5 | ||
| Capital Component Profit Ceiling Percentage | ||
| Effective Date | July 1, 2003, through June 30, | July 1, |
| Percentage | 100% | 80% |
(C) The allowed capital component profit add-on payment is equal to the facility's tentative capital component profit add-on payment times the applicable percentage contained in Table 3, based on the facility's nursing home report card score as determined by the office or its contractor using the latest published data as of the end of each state fiscal year, or the facility's total quality score. as applicable.
(5) The therapy component profit add-on is equal to zero (0).
(c) Notwithstanding subsections (a) and (b), in no instance shall a rate component exceed the overall rate ceiling defined as follows:
(1) The normalized average allowable cost of the median patient day for direct care costs times the facility-average CMI for Medicaid residents times the overall rate ceiling percentage in Table 6.
| Table 6 | ||
| Direct Care Component Overall Rate Ceiling Percentage | ||
| Effective Date | July 1, 2003, through June 30, | July 1, |
| Percentage | 120% | 110% |
(2) The average allowable cost of the median patient day for indirect care costs times the overall rate ceiling percentage in Table 7.
| Table 7 | ||
| Indirect Care Component Overall Rate Ceiling Percentage | ||
| Effective Date | July 1, 2003, through June 30, | July 1, |
| Percentage | 115% | 100% |
(3) The average allowable cost of the median patient day for capital-related costs times the overall rate ceiling percentage in Table 8.
| Table 8 | ||
| Capital Component Overall Rate Ceiling Percentage | ||
| Effective Date | July 1, 2003, through June 30, | July 1, |
| Percentage | 100% | 80% |
(4) For the therapy component, no overall rate component limit shall apply.
(d) In order to determine the normalized allowable direct care costs from each facility's Financial Report for Nursing Facilities, the office or its contractor shall determine each facility's CMI for all residents on a time-weighted basis.
(e) The office shall publish guidelines for use in determining the time-weighted CMI. These guidelines:
(Office of the Secretary of Family and Social Services; (1) shall be published as a provider bulletin; and
(2) may be updated by the office as needed.
Any such updates shall be made effective no earlier than permitted under IC 12-15-13-6 (a).
SECTION 11. 405 IAC 1-14.6-18 IS AMENDED TO READ AS FOLLOWS:
405 IAC 1-14.6-18 Allowable costs; calculation of allowable owner or related party compensation; wages; salaries; fees
Authority: Affected: IC 12-13-7-3 ; IC 12-15
Sec. 18. (a) Compensation for:
(1) an owner, a related party, management, general line personnel, and consultants who perform management functions; or
(2) any individual or entity rendering services above the department head level;
shall be subject to the annual limitations described in this section. All compensation received by the parties as described in this subsection shall be reported and separately identified on the financial report form even though such payment may exceed the limitations. This compensation is allowed to cover costs for all administrative, policymaking, decision making, and other management functions above the department head level. Beginning effective July 1, 2003, Through June 30, 2014, 2017, compensation subject to this limitation includes wages, salaries, and fees for the owner, management, contractors, and consultants who actually perform management functions as well as any other individual or entity performing such tasks. Beginning effective July 1, 2014, 2017, and thereafter, wages, salaries, and fees paid for the owner, administrator, assistant administrator, management, contractors, and consultants who actually perform management functions as well as any other individual or entity performing such tasks are subject to this limitation.
(b) Beginning effective July 1, 2003, Through June 30, 2014, 2017, the maximum allowable amount for owner, related party, and management compensation shall be the average allowable cost of the median patient day for owner, related party, and management compensation subject to this limitation as defined in subjection (a). The average allowable cost of the median patient day shall be updated four (4) times per year effective January 1, April 1, July 1, and October 1.
(c) Beginning effective July 1, 2014, 2017, the maximum amount of owner, related party, and management compensation for the parties identified in subsection (a) shall be the lesser of the amount:
(1) under subsection (d), as updated by the office on July 1 of each year based on the average rate of change of the most recent twelve (12) quarters of the Gross National Product Implicit Price Deflator; or
(2) of patient-related wages, salaries, or fees actually paid or withdrawn that were properly reported to the federal Internal Revenue Service as wages, salaries, fringe benefits, or fees.
If liabilities are established, they shall be paid within seventy-five (75) days after the end of the accounting period or the costs shall be disallowed.
(d) The owner, related party, and management compensation limitation per operation effective July 1, 1995, shall be as follows:
(Office of the Secretary of Family and Social Services; | Owner and Management Compensation | |
| Beds | Allowance |
| 10 | $21,542 |
| 20 | $28,741 |
| 30 | $35,915 |
| 40 | $43,081 |
| 50 | $50,281 |
| 60 | $54,590 |
| 70 | $58,904 |
| 80 | $63,211 |
| 90 | $67,507 |
| 100 | $71,818 |
| 110 | $77,594 |
| 120 | $83,330 |
| 130 | $89,103 |
| 140 | $94,822 |
| 150 | $100,578 |
| 160 | $106,311 |
| 170 | $112,068 |
| 180 | $117,807 |
| 190 | $123,562 |
| 200 | $129,298 |
| 200 and over | $129,298 + $262/bed over 200 |
This subsection applies to each provider of a Medicaid-certified operation. The unused portions of the allowance for one (1) operation shall not be carried over to other operations.
SECTION 12. 405 IAC 1-14.6-24 IS AMENDED TO READ AS FOLLOWS:
405 IAC 1-14.6-24 Nursing facility quality assessment
Authority: Sec. 24. (a) Effective from July 1, 2011, through September 30, 2011, the office shall collect a quality assessment from each nursing facility licensed under IC 16-28 as a comprehensive care facility based on the most recently completed annual financial report or quality assessment data collection form, as follows:
(1) Privately owned or operated nursing facilities with total annual nursing facility census days fewer than seventy thousand (70,000), fourteen dollars and seventy cents ($14.70) per non-Medicare day.
(2) Privately owned or operated nursing facilities with total annual nursing facility census days equal to or greater than seventy thousand (70,000), three dollars and sixty-eight cents ($3.68) per non-Medicare day.
(3) Nonstate government owned or operated nursing facilities that became nonstate government owned or operated before July 1, 2003, three dollars and sixty-eight cents ($3.68) per non-Medicare day.
(4) Nonstate government owned or operated nursing facilities that became nonstate government owned or operated on or after July 1, 2003, fourteen dollars and seventy cents ($14.70) per non-Medicare day.
(1) Privately owned or operated nursing facilities with total annual nursing facility census days fewer than seventy sixty-two thousand (70,000), (62,000), sixteen dollars ($16) and thirty-seven cents ($16.37) per non-Medicare day.
(2) Privately owned or operated and nonstate government owned or operated nursing facilities with total annual nursing facility census days equal to or greater than seventy sixty-two thousand (70,000), (62,000), four dollars ($4) and nine cents ($4.09) per non-Medicare day.
(3) Nonstate government owned or operated nursing facilities that became nonstate government owned or operated before July 1, 2003, four dollars ($4) and nine cents ($4.09) per non-Medicare day.
(4) Nonstate government owned or operated nursing facilities that became nonstate government owned or operated on or after July 1, 2003, with total annual nursing facility census fewer than sixty-two thousand (62,000), sixteen dollars ($16) and thirty-seven cents ($16.37) per non-Medicare day.
(1) A continuing care retirement community that meets one (1) of the following:
(A) A continuing care retirement community that was registered with the securities commissioner as a continuing care retirement community on or before January 1, 2007, and that has continuously maintained at least one (1) continuing care agreement since on or before January 1, 2007, with an individual residing in the continuing care retirement community.
(B) A continuing care retirement community that for the entire period from January 1, 2007, through June 30, 2009, operated independent living units, at least twenty-five percent (25%) of which are provided under contracts that require the payment of a minimum entrance fee of at least twenty-five thousand dollars ($25,000).
(C) An organization registered under IC 23-2-4 before July 1, 2009, that provides housing in an independent living unit for a religious order.
(D) A continuing care retirement community that meets the definition set forth in IC 16-28-15-2 .
(2) A hospital-based nursing facility licensed under IC 16-21 .
(3) The Indiana Veterans' Home.
(1) In writing.
(2) Contain the following:
(A) Specific issues to be reconsidered.
(B) The rationale for the facility's position.
(3) Signed by the authorized representative of the facility and must be received by the contractor not later than forty-five (45) days after the notice of the assessment is mailed.
Upon receipt of the request for reconsideration, the Medicaid rate-setting contractor shall evaluate the data. After review, the Medicaid rate-setting contractor may amend the assessment or affirm the original decision. The Medicaid rate-setting contractor shall thereafter notify the facility of its final decision in writing, within forty-five (45) days of the Medicaid rate-setting contractor's receipt of the request for reconsideration. In the event that a timely response is not made by the rate-setting contractor to the facility's reconsideration request, the request shall be deemed denied and the provider may initiate an appeal under IC 4-21.5-3 .
(1) In writing setting forth the facility's rationale for the request.
(2) Submitted to the office or its designee.
An installment plan established under this section shall not exceed a period of six (6) months from the date of execution of the agreement. The agreement shall set forth the amount of the assessment that shall be paid in installments and include provisions for the collection of interest. The interest shall not exceed the percentage set out in IC 12-15-21-3 (6)(A).
(1) Against a Medicaid payment to the facility.
(2) Against a Medicaid payment to another health facility that is related to the facility through common ownership or control.
(3) In another manner determined by the office.
(1) fails to submit patient day information requested by the office to calculate the quality assessment fee; or
(2) fails to pay the quality assessment fee;
not later than one hundred twenty (120) days after the patient day information is requested, or payment of the quality assessment is due, the office shall report each facility to the state department of health to initiate license revocation proceedings in accordance with IC 16-28-15-12 .
SECTION 13. 405 IAC 1-14.6-26 IS AMENDED TO READ AS FOLLOWS:
405 IAC 1-14.6-26 Rate reduction
Authority: Affected: IC 12-13-7-3 ; IC 12-15
Sec. 26. Notwithstanding all other provisions of this rule, for the period beginning January 1, 2014, and continuing through June 30, 2015, reimbursement rates shall be reduced by three percent (3%) per resident day, through June 30, 2017, for nursing facility services that have been calculated under this rule except for the following:
(Office of the Secretary of Family and Social Services;
(1) The difference between:
(A) the nursing facility quality rate add-on, as described in section 7(m) of this rule; and
(B) the nursing home report card score rate add-on calculated using each facility's current nursing home report card score, and the nursing home report card score rate add-on parameters contained in 405 IAC 1-14.6-7 (k) of LSA Document #10-183, posted as a final rule in the Indiana Register at 20101201-IR-405100183FRA , effective December 1, 2010.
(2) The difference between:
(A) the quality assessment rate add-on, as described in section 24(a) of this rule; and
(B) the quality assessment rate add-on calculated using the assessment rates in 405 IAC 1-14.6-24 (a) of LSA Document #10-65, posted as a final rule in the Indiana Register at 20101201-IR-405100065FRA , effective December 1, 2010.
SECTION 14. 405 IAC 1-19-2 IS AMENDED TO READ AS FOLLOWS:
405 IAC 1-19-2 Time and manner of disclosure
Authority: Affected: IC 12-13-7-3 ; IC 12-15
Sec. 2. (a) Any disclosing entity that is a long term care facility must supply the information specified in this rule to the Indiana state department of health at the time it is surveyed.
(b) Any disclosing entity that is not a long term care facility must supply the information specified in this rule to the office or its fiscal agent at any time there is a change in ownership or control.
(c) Any new provider must supply the information specified in this rule at the time of filing a complete application.
(d) Any provider must supply the information specified in this rule upon executing the provider agreement.
SECTION 15. 405 IAC 1-20-2 IS AMENDED TO READ AS FOLLOWS:
405 IAC 1-20-2 Notification requirements
Authority: Affected: IC 12-13-7-3 ; IC 12-15
Sec. 2. (a) When a change of ownership in a long term care facility is contemplated, the transferor provider shall notify the office, or its fiscal agent, no less than forty-five (45) days prior to the effective date of sale or lease agreement that a change of ownership may take place.
(b) Notification shall be in writing and include the following:
(1) A copy of the agreement of sale or transfer.
(2) The expected date of transfer.
(3) If applicable, the name of any individual who has an ownership or control interest, is a managing employee, or an agent of the transferor, who will also hold an ownership or control interest, be a managing employee, or be an agent of the transferee.
(c) The transferee shall make application to the office for an amendment to the transferor's provider agreement no less than forty-five (45) days prior to the expected date of transfer in accordance with this rule and 405 IAC 1-14.6-5 (c).
(d) If notification requirements from both the transferor and the transferee have not been met on or before the forty-fifth day before the effective date of the change of ownership, all Medicaid payments due to the transferor will may be held until such time as the information is received, reviewed, and approved for completeness. Any payments held will not be held paid, until such time as the transferee has fulfilled enrollment requirements in the Medicaid program as set forth in the provider manual and provider enrollment packet.
(e) The effective date of the change of ownership will be determined by the Indiana state department of health's certification and transmittal and amended by the Indiana state department of health, if necessary, to correspond with the transferor/transferee agreement of sale or transfer.
(Office of the Secretary of Family and Social Services;
SECTION 16. 405 IAC 5-24-6 IS AMENDED TO READ AS FOLLOWS:
405 IAC 5-24-6 Dispensing fee
Authority: Affected: IC 12-13-7-3
Sec. 6. (a) For purposes of this rule, through June 30, 2017, the Indiana Medicaid dispensing fee maximum is four dollars and ninety cents ($4.90) per legend drug. For the period beginning upon the later of the effective date of this rule or January 1, 2014, and continuing through June 30, 2015, the Indiana Medicaid dispensing fee maximum is three dollars and ninety cents ($3.90) per legend drug.
(b) A maximum of one (1) dispensing fee per month is allowable per recipient per drug order for legend drugs provided to Medicaid recipients residing in Medicaid certified long term care facilities.
(c) The practice of split billing of legend drugs, defined as the dispensing of less than the prescribed amount of drug solely for the purpose of collecting more dispensing fees than would otherwise be allowed, is prohibited. In cases in which the pharmacist's professional judgment dictates that a quantity less than the amount prescribed be dispensed, the pharmacist should contact the prescribing practitioner for authorization to dispense a lesser quantity. The pharmacist must document the result of the contact and the pharmacist's rationale for dispensing less than the amount prescribed on the prescription or in the pharmacist's records.
(Office of the Secretary of Family and Social Services;
SECTION 17. 405 IAC 5-24-13 IS AMENDED TO READ AS FOLLOWS:
405 IAC 5-24-13 Legend and nonlegend solutions for nursing facility residents
Authority: Affected: IC 12-13-7-3 ; IC 12-15
Sec. 13. The cost of legend and nonlegend water products in all forms and for all uses, used for irrigation or humidification are included in the per diem rate for nursing facilities. When these drugs water products used for irrigation or humidification are furnished to a nursing facility resident, they are not separately reimbursable by Medicaid and are not to be billed separately to Medicaid by either the nursing facility or another Medicaid provider furnishing the products, as set forth in 405 IAC 5-31-4 (7). Water agents used (or to be used) as a vehicle to deliver a drug therapy into the body must be reimbursed through the pharmacy benefit and not included in the nursing facility per diem reimbursement.
(Office of the Secretary of Family and Social Services;
SECTION 18. 405 IAC 5-24-14 IS ADDED TO READ AS FOLLOWS:
405 IAC 5-24-14 Skin protectants, sealants, moisturizers, and ointments for nursing facility residents
Authority: Affected: IC 12-13-7-3 ; IC 12-15
Sec. 14. (a) The cost of skin protectants, sealants, moisturizers, and ointments for nursing facility residents are to be reimbursed as follows:
(1) Skin protectants, sealants, moisturizers, and ointments that are applied on an as needed basis, by the member, nursing facility care staff, or by prescriber's order, as a part of routine care, as defined in 405 IAC 1-14.6-2 (gg), must be included in the per diem reimbursement and must not be reimbursed through the pharmacy benefit.
(2) If all of the following conditions are met, skin protectants, sealants, moisturizers, and ointments must be reimbursed through the pharmacy benefit:
(A) Legend or nonlegend (listed on the OTC drug formulary only).
(B) Prescribed for regular application or applications, or both, as a single agent or compounded with other drug agents.
(C) Used to treat or ameliorate a defect or physical or mental illness or condition.
(b) Non-drug skin protectants, sealants, moisturizers, and ointments must be reimbursed through the pharmacy benefit only when they are compounded with other drug agents, otherwise they are to be included in the per diem reimbursement, as set forth in 405 IAC 5-31-4 (8).
(Office of the Secretary of Family and Social Services;
SECTION 19. 405 IAC 5-31-4 IS AMENDED TO READ AS FOLLOWS:
405 IAC 5-31-4 Per diem services
Authority: Affected: IC 12-13-7-3 ; IC 12-15
Sec. 4. Those services and products furnished by the facility for the usual care and treatment of patients are reimbursed in the per diem rate in accordance with 405 IAC 1-14.6 . The per diem rate for nursing facilities includes the following services:
(Office of the Secretary of Family and Social Services; (1) Room and board (room accommodations, all dietary services, and laundry services). The per diem rate includes accommodations for semiprivate rooms. Medicaid reimbursement is available for medically necessary private rooms. Private rooms will be considered medically necessary only under one (1) or both of the following circumstances:
(A) The recipient's condition requires isolation for health reasons, such as communicable disease.
(B) The recipient exhibits behavior that is or may be physically harmful to self or others in the facility.
(2) Nursing care.
(3) The cost of all medical and nonmedical supplies and equipment, which includes those items generally required to assure adequate medical care and personal hygiene of patients. is included in the nursing facility per diem.
(4) Durable medical equipment (DME), and associated repair costs, routinely required for the care of patients, including, but not limited to:
(A) ice bags;
(B) bed rails;
(C) canes;
(D) walkers;
(E) crutches;
(F) standard wheelchairs; and
(G) traction equipment; and
(H) oxygen and equipment and supplies for its delivery;
are covered in the per diem rate and may not be billed to Medicaid by the facility, an outside pharmacy, or any other provider. Nonstandard items of DME and associated repair costs that have received prior authorization must be billed to Medicaid directly by the DME provider. Facilities may not require recipients to purchase or rent such equipment with their personal funds. DME purchased with Medicaid funds becomes the property of the office of Medicaid policy and planning. The county office of family and children must be notified when the recipient no longer needs the equipment.
(5) Medically necessary and reasonable therapy services, which include physical, occupational, respiratory, and speech pathology services.
(6) Transportation to vocational/habilitation service programs.
(7) The cost of both legend and nonlegend water products in all forms and for all uses. used for irrigation or humidification must be included in per diem reimbursement and must not be reimbursed through the pharmacy benefit. Water agents used alone (not intended to deliver a drug) for irrigation or humidification must be included in per diem reimbursement and must not be reimbursed through the pharmacy benefit.
(8) Skin protectants, sealants, moisturizers, and ointments that are applied on an as needed basis, by the member, nursing facility care staff, or by prescriber's order, as a part of routine care, as defined in 405 IAC 1-14.6-2 (gg), must be included in the per diem reimbursement and must not be reimbursed by the pharmacy benefit.
LSA Document #15-34(F)
Notice of Intent: 20150128-IR-405150034NIA
Proposed Rule: 20150304-IR-405150034PRA
Hearing Held: March 26, 2015
Approved by Attorney General: April 14, 2015
Approved by Governor: April 16, 2015
Filed with Publisher: April 29, 2015, 3:38 p.m.
Documents Incorporated by Reference: None Received by Publisher
Small Business Regulatory Coordinator: Joy Heim, Indiana Family and Social Services Administration, Office of Medicaid Policy and Planning, Indiana Government Center South, 402 West Washington Street, Room W374, Indianapolis, IN 46204, (317) 234-4753, joy.heim@fssa.in.gov
Posted: 05/27/2015 by Legislative Services Agency
DIN: 20150527-IR-405150034FRA
Composed: Apr 28,2024 7:50:12AM EDT
A PDF version of this document.